Provider Demographics
NPI:1124078449
Name:PARK, EUNJIN (PA)
Entity type:Individual
Prefix:
First Name:EUNJIN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PERRYRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4608
Mailing Address - Country:US
Mailing Address - Phone:914-282-9880
Mailing Address - Fax:
Practice Address - Street 1:5 PERRYRIDGE RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4608
Practice Address - Country:US
Practice Address - Phone:914-282-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00138500363A00000X
CT002071363AM0700X
NY009684363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ089380Medicare PIN
Q24183Medicare UPIN